Jeffrey Braithwaite

We hear it all the time: the population is ageing. For the health system, the numbers are frightening. Since 1960 the world's population has grown from 3 billion to 7.2 billion. By 2025 it will have passed 8 billion.
And the billions are getting older.

In developed countries the over-60s now make up more than 20 per cent of the population. By the 2030s they will make up 30 per cent – in Japan and Switzerland, 40 per cent.

As this bulging cohort of oldies approaches, medical treatments are stretched. Hospital stays have become shorter over the last 30 years. Treat quicker and discharge fast is increasingly the strategy.

Where will the patients go? As the years roll on, more and more homes in our suburbs and residential aged care facilities will house old people who are being cared for – or are caring for themselves – supported by travelling medical and geriatric services.

This means new ways of doing things: interconnected health services delivered outside hospitals, visiting clinicians caring for people in community settings, and systems to transfer patients flexibly in and out of primary, home or aged care, or rehabilitation when needed.

It also implies new ways of thinking. Our focus must move from episodes of care (think of the single consultation, followed by the admission, then treatment, and then discharge) to take in the entire patient journey – each one different – throughout the complex care environment.

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Some countries are well ahead of Australia here. Those with rapidly ageing populations (Japan, Canada, Switzerland) offer a glimpse of our future. Hospital beds are being cut back in favour of day procedures and community healthcare. Japan aims to move from 8500 to 7000 hospitals within 15 years. All three countries are creating more retirement home beds and aged-care facilities and expanding geriatrics training. In Canada and Japan primary health services are being reorganised into communities of physicians to improve co-ordination and coverage and reduce costs.

Baby Boomers are the key to change. They're the most educated, the richest and most demanding group. Ever. They want their painful knees fixed, heart disease managed, and cancer put into remission. Immediately. At their convenience, not the health system's. Even if it's public healthcare they're receiving.

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As Australia negotiates this transition, important questions arise about the future shape of the care system. The issue underlying them all is how to make healthcare sustainable and responsive. We need a system built to last, and flexible for patients. This hints at the direction change is taking. It pivots on the use of technology. Electronic health records provide access to patients' details, past histories and care plans, so the whole health team and the patient can share them. But they are very costly – and what if IT systems fail?

That's not just a remote possibility. Hollywood Presbyterian Hospital in LA was hacked in February, and forced to pay a $US17,000 ($22,000) ransom. Hospital staff had to write up patients' documentation by hand, and they sent 911 patients they couldn't treat to nearby hospitals. The computers were down for a week – plenty of time for patients to die or be harmed by the absence of diagnostic tests and clinical information, although the hospital reported no deaths as a result.

The month before, a computer virus caused chaos at Royal Melbourne Hospital. Pathology tests and patients' meals had to be sorted out manually, with staff doing workarounds to get the right meals and results to the right patients.

All the same, try to stop the march of progress or the ubiquity of IT. As the focus of treatment moves out from hospitals more into the community, telehealth will contribute to improving access and better outcomes. Many tests or services which are now performed in hospitals will be carried out in people's homes or lower-cost locations. But which ones? And will patients be at more risk of things going wrong, with no back-up at home? Or will people still prefer the time-honoured psychological comfort of going into hospital, even when it's not entirely necessary?

This is where patients' preferences come in. Those rich, educated, IT-savvy Baby Boomers will demand the care they want, in the setting they want, when they judge they need it, on their terms. And it'll have to be IT-enabled and free from hacking or viruses.

At present we don't know how we'll create this responsiveness – or pay for it. But we do know the forces which are driving change – new technology, new drugs, new methods plus the demands of an ageing, better educated, more confident population. These, along with the system we already have, are the knowns from which our unknown future healthcare will be created.

It has to be sustainable for the long term. To achieve that on our limited budget, we need a far better idea of how the existing system works – how it succeeds, how it fails, and how technology can improve it. That is the challenge for today's health administrators.

Professor Jeffrey Braithwaite is founding director of the Australian Institute of Health Innovation at Macquarie University.